Hemodynamics and Shock

Module 6: Hemodynamics and Shock

• Hypovolemic shock features low fluid and high hematocrit.
• Hemorrhage presents with low hemoglobin and low hematocrit.
• Signs of shock include decreased MAP (<65), cool, clammy skin, diaphoresis, altered mental status, decreased urine output, and sluggish capillary refill.
• CVP should be about ½ of PAWP.

Shock Types

• Hypovolemic/hemorrhagic shock is caused by dehydration, bleeding, burns, vomiting, diarrhea, extreme sweating, ascites, diabetes insipidus (excessive urine output), overuse of diuretics or laxatives, hyperthermia, or Stevens-Johnson Syndrome (SJS).
  • It shows decreased CVP and PAWP, and increased SVR.
  • It results in decreased cardiac preload.
  • Treatment is always to use isotonic fluids for replacement.
• Cardiogenic shock results from heart pump or electrical problems (MI, HF, arrhythmias).
  • It shows increased CVP and PAWP and increased SVR.
• Distributive shock is caused by severe vasodilation (anaphylaxis, septic, neurogenic, SIRS, endocrine shock).
  • SVR is decreased in this type.
• Obstructive shock is caused by tension pneumothorax, pulmonary embolism (PE), or cardiac tamponade.

Preload, Afterload, and Contractility

• Preload indicates fluid volume.
• Afterload indicates resistance.
• Contractility indicates pumping ability.

Oxygen Saturation

• A drop in O2 saturation can indicate fluid volume overload in the lungs, which is indicative of cardiogenic shock.
• Cardiogenic shock has a high mortality rate (50%).
  • Impella pump has improved outcomes in the past 10 years.
  • It can increase cardiac output up to 5 LPM versus a max 1.5 LPM increase from inotropes.

Cases

• Lactic acid indicates poor perfusion.
• High sodium may indicate dehydration.
• High potassium may be caused by vomiting, diarrhea, BUN or creatinine increases.

Hemodynamic Parameters

• Normal CVP: 2-6 mmHg
• Normal PAWP: 4-12 mmHg
• Normal CO: 4-8 LPM
• Normal CI: 2.5-4.5 L/min/m2
• Normal SVR: 800-1400 dynes/sec/cm-5
• Patient values of CVP 1 mmHg, PAWP 3 mmHg, CO 3.1 LPM, CI 2.3 L/min/m2, SVR 2100 dynes/sec/cm-5, indicates hypovolemic shock

Treatment of Shock

• Hypovolemic shock is treated with isotonic fluids; use blood products it is caused by bleeding
• Septic shock treatment includes norepinephrine (until MAP >65), oxygen via non-rebreather mask, antibiotics, and saline boluses.
• Cardiogenic shock treatment (post MI) may include aspirin and milrinone (to increase CO).

LVAD

• With an LVAD, there is no blood pressure and no pulse.
• Preload is measured by CVP and PAWP, which reflect fluid status.
• Afterload is measured by SVR, which indicates vasodilation or vasoconstriction (only decreases in septic, anaphylactic, and neurogenic shock).
• CVP measures R side of heart function. (pumps to lungs)
• PAWP measures L side of heart function. (pumps to body)
• SVR measures the resistance of blood flow out of the L ventricle.
• Furosemide can be given for high PAWP and CVP.
• Fluid boluses can be given for low PAWP and CVP.

Cardiac output

• Low CO/CI can be caused by MI, bleeding, dehydration, metoprolol, or increased HR.
• Give furosemide if CVP is high but CI is normal.
• Give an inotropic agent if CVP is high but CI is decreased.
• Fluid overload can decrease CI, though inotropic agents are used if the CI index is decreased.

Medications

• Do not give furosemide if CI is low due to potentially dropping the MAP more.
• Dobutamine is for cardiogenic shock only when MI or other issues are decreasing CO/CI.

Scenario

• A patient with ascites and fluid shifting will be in hypovolemic shock due to low fluid in the tissues.
• Ascites can cause low albumin.
• Albumin keeps fluid in blood vessels by creating oncotic pressure, which prevents fluid from leaking to surrounding tissues.
• Give albumin if low. It helps bring fluid back into the correct space and keep from leaking.

Case Study

• A patient with pneumonia showing T 102.8 F, P 105 bpm, BP 100/70 mmHg (MAP = 80 mmHg), RR 28 bpm, 94% on room air and CVP 1 mmHg, PAWP 3 mmHg, CO 4 LPM, CI 2.8 L/min/m2, and SVR 1000 dynes/sec/cm-5.
• Treatments to expect would be Norepinephrine, Antibiotics, Oxygen non rebreather.
• Norepinephrine should be given even with normal numbers due to signs of infection.
• SVR and CI are relatively low, and CO is borderline low.

Hemodynamic Values Matching

• CVP = 1 mmHg; PAWP = 2 mmHg; CO= 3.5 LPM; CI = 2.3 L/min/m2; sodium = 140 mEq/L; hemoglobin = 6 g/dL; hematocrit =30% = Hemorrhagic shock needing blood transfusion
• CVP = 18 mmHg; PAWP = 22 mmHg; CO = 5 LPM; CI = 2.6 L/min/m2 = No shock present; need furosemide for fluid overload
• CVP = 14 mmHg; PAWP = 20 mmHg; CO = 3.5 LPM; CI = 2.0 L/min/m2; contractility low = Cardiogenic shock needing inotropic agent
• CVP = 3 mmHg; PAWP = 6 mmHg; CO = 2.8 LPM; CI = 1.5 L/min/m2; SVR = 400 dynes/sec/cm-5; WBC count = 45 cells/mcL = Septic shock needing nerepinephrine and antibiotics
• CVP = 15 mmHg; PAWP = 26 mmHg; CO = 3.8 LPM; CI = 1.8 L/min/m2; HR = 220 bpm; rhythm = SVT = Cardiogenic shock needing adenosine
• CVP = 1 mmHg; PAWP = 2 mmHg; CO 3 LPM; CI = 2 L/min/m2; sodium = 150 mEq/L; Hgb = 15 g/dL; Hct = 45% = Hypovolemic shock needing normal saline

Module 7: Critical Rhythms and Pacemakers

• AV block is a rhythm where an electrical impulse cannot make it from the atria to the ventricles.
• Two problems that can occur in an atrioventricular block include slowing of conduction from the atria to the ventricle (PR interval > 0.20 secs).
• Second problem that can occur in an atrioventricular block is more than one P-wave to each QRS.

First Degree AV Block

• Electrical impulse is delayed but still reaches the ventricles.
• ECG Findings: PR interval > 0.20 sec (more than 5 small boxes) and a regular rhythm (each P wave still leads to a QRS complex).
• There are no dropped beats.
• Mnemonic: "If the R is far from P, then you have a first-degree."
• Clinical significance: Can be caused by beta-blockers, calcium channel blockers, digoxin, or ischemia.
• Treatment: Usually not needed unless symptomatic (adjust medications or use Atropine 1 mg IVP if needed).

Defibrillation Vs Cardioversion

• Whether or not there is a QRS complex on the rhythm determines when to defibrillate and when to cardiovert.
• SVT and A-Fib have an identifiable QRS complex, so the machine can synchronize to it.
• VF does not have a good QRS complex, so unsynchronized shock is delivered.
• Sometimes VT can be cardioverted.
• The only type of defibrillator shock is unsynchronized, and only type of cardioversion available is synchronized.

Second Degree AV Block Type 1 (Mobitz I / Wenckebach)

• The definition is a progressive delay at the AV node until a QRS is dropped.
• This is a true block where there are more P waves than QRSs.
• PR interval has a difference throughout the rhythm strip (progressive prolongation).
• ECG Findings: progressive PR interval until a QRS is dropped, Grouped beating, Irregular rhythm
• Mnemonic: "Longer, longer, longer, drop then you have a Wenckebach."
• Clinical significance: Can be benign but may cause symptoms (dizziness, syncope).
• Commonly caused by medications (beta-blockers, digoxin, CCBs) or inferior MI.
• Treatment: Monitor if stable and atropine 1 mg IVP or pacing if symptomatic.

Second Degree AV Block Type 2 (Mobitz II)

• Definition: Intermittent failure of conduction without warning.
• PR intervals are the same, but there are more P waves than QRS complexes.
• ECG Findings: constant PR interval before a sudden dropped QRS, more P waves than QRS complexes, usually a wide QRS, and irregular ventricular rhythm.
• Mnemonic: "If some P's don't get through, then you have a Mobitz II."
• Clinical significance: More dangerous than Type 1 because it can progress to 3rd-degree block.
• Caused by structural heart disease (MI, fibrosis, ischemia).
• Treatment: do not give Atropine and immediately prepare transcutaneous pacing → permanent pacemaker.

QRS Complex

• Narrow QRS complexes come from the atrium (0.04-0.12 secs).
• Wide QRS complexes come from the ventricles (>0.12 secs).

Third Degree AV Block

• Complete failure of the AV node—atria and ventricles beat independently.
• Definition: Complete failure of the AV node—atria and ventricles beat independently.
• ECG Findings: P waves and QRS complexes are completely dissociated, no relationship between P waves and QRS, and regular P waves & regular QRS, but they don't correspond.
• Escape rhythms: narrow QRS is junctional escape, wide QRS is ventricular escape.
• Mnemonic: "If P's and Q's don't agree, then you have a third-degree."
• Clinical significance: Medical emergency that can lead to severe bradycardia, syncope, or asystole.
• Treatment: Transcutaneous pacing immediately followed by permanent pacemaker.

Steps for Transcutaneous pacing

1. Place pads on patient
2. Turn on pacer mode
3. Increase mAs until capture is obtained
4. Adjust pacer rate until desired rate has also been achieved
5. Reassess VS
6. Give patient sedation and pain meds LASTTT (don't do first it can lower BP)

Polymorphic Vs Monomorphic VT

• Monomorphic VT looks the same throughout (one problem area).
• Polymorphic VT looks different (different problem areas more than one).
• Ventricular Tachycardia shows Wide QRS and looks bizarre, like a tombstone with a fast rate.

Causes of VT

• Abnormal K or other electrolyte levels
• MIs
• Med toxicity (digoxin)
• Heart diseases

Treatments for VT

1. Stable patient VT with a pulse: amiodarone 150 mg IVP
2. Unstable VT with pulse: cardiovert the patient
3. Patient has VT and NO pulse: start CPR immediately then defibrillate the patient

Meds that increase QT intervals

• Amiodarone
• Sotalol
• Procainamide
• Low calcium, K or magnesium
• The electrolyte to be given to correct patient in Torsades is called magnesium sulfate.
• Amiodarone will not work when treating Torsades.

Defibrillation vs Cardioversion

• Unsynchronized, meaning the shock is delivered without regard to the heart's electrical rhythm in defibrillation.
• Synchronized, meaning the shock is timed to coincide with a specific point in the heart's electrical cycle to avoid further disruption in cardioversion.
• Blocks PNS is how Atropine works.

Terms

• Asystole is no electrical activity in the heart. Treat with CPR and epi every 3-5 minutes.
  • DO NOT SHOCK THIS RHYTHM and vasopressin or atropine cannot be used.

Treatment for PEA

• Clinically dead but electrical activity is present in the heart, but not pulse.
• Treat the same as asystole, give epi and CPR and no shocking !!

Indications for Pacemaker

• Symptomatic bradycardia is the major indication for a pacemaker
• AV blocks are the most common cause
• HF, MI, Heart surgery can lead to symptomatic bradycardia
• Teaching includes it is okay to swim.
  • To drive after 2 weeks
  • No raising arm above head for 2 weeks
  • No heavy lifting
  • Check pulses daily
  • Avoid microwaves, metal detectors and mp3 earphones and stereos

Types of Pacemakers

• Atrioventricular pacemaker- wire placed in the right atrium and right ventricle
• Biventricular pacemaker- wires in both ventricles. Also atrio-biventricular pacemakers. For patients with advanced HF/Cardiomyopathy

When to give Epinephrine

• During CPR and defibrillation?
• After 2nd shock

ACLS Considerations

• Correct includes Push hard on the chest at least 2 inches,Change compressor every 2 minutes or more frequently if the compressor is fatigued, Avoid excessive ventilations by giving 1 breath every 6 seconds if an advanced airway is in place.
• Not correct includes interrupt compressions for inserting IV or advanced airway, Perform compression to ventilation ratio of 15:2, Push fast on the chest at a rate of 100-150/minute

Digoxin Toxicity Considerations

• MS changes, irregular pulse, N,V,D VISON CHANGES, syncope, dyspnea are common.
• Increased risk w furosemide and decreased K

End Of Life Considerations

• Two people must be called,
• Transplant alliance (skin and cornea (avascular) can be used after death),
• medical examiner (not every pt needs. called , any pt in her case needs called becuase in less than 24 hrs)
• all patients in hospital must be reported in <24 hours
• Do NOT MOVE ALL THINGS- until instructed to do so

After Determination of Death

• Dont REMOVE ANYTHINGGGG FROM PATIENT UNTIL CLEARED BY ME
• everything attached to body MUST go to ME office
• every single tube, drain, bag of med or fluid, etc
• DO NOT take bags down , everything goes with patient to ME
• LEAVE CENTRAL AND PICC LINES IN PLACE, for the funeral home to embalm the body
• If family is not at a bedside , do not call them, ask
• Never used passed or expired wording, used words like , death
• The body stay in the room
• Get funeral information as soon as possible

Module 8: Valvular Heart Disease, Disease of Aorta

• BP is systole/ diastole and heart is contracting during higher number
• in ventricular diastole relaxation phase of ventriclre, blood moves from atria
• During ventricular systole, ventricles constrict, blood moves to circulatory system
• In aortic regurgitation, backflow of bloody leads to turbulent flow and then heart has to compensate.
• Overtime, the ventricular weakens and that equals HF
• Pulmonic valve- right ventricle moves to pulmonary artery.
• Aortic valve runs to aorta

Valve Stenosis

• Back up of blood in prec.chambers and murmur can be heard cuz blood flow
• murmur heard bc of turbulent blood flow blood is in chamber
• Triad syncope, angina, dyspnea
  • Angina is most common( within 5 years 50% die)
  • Syncope(50% mortality) in 3 years
• HF( is 50% dies in 2years)

After Transcatheter Procedure

• Monitor for Stroke signz and bleeding
• TAVR
• Why is that pt at that high risk
• calcium debris from old valve
• atherosclerotic plaque
• strokes will be TPA resistance
• Pulm.Edemas occurs
• Back up and systemic cicrulation
• stenosis happens by
• abnormal formation of heart
• inflammation, calcium build-up Elevated calcium,fibrosis
• valve controls flow from heart out of
• Aortic stenosis indicated @ sternal

Aortic Issues and Treatments

• Scattered crackles means pulmonary backflow
• 2 Main tx is to relieve the obstruction.
• Aortic Regurt,Medications
• L Ventrics fails/Aortic Regurt
  • Arterial ( blockers, Ace)
  • Diuretics
  • AvoID constrictors

Mitral Stenosis

• Is lower pitched
• Heard to apex -
• Three goals treat A fib Backflow

Mitral Regurt

• Medical
• HR, reduce overload
• surgical
• valve repair

Heart Surgery and Cardiac

• Risk for Heart Problems
• Lower bpr
• Medications
• Lifestyle Modifications

Module 9 Sepsis and Shock

• Involves infectiion or inflammatory Response
• 2/or MORE more have Sirs+ info= sepsis
• 2 hour window
• give IV fluids n or LR
• Early phase is warm

Disseminated Coagualation,DIC

• Major Resaon is Sepsis leading to clotting accelerated
• Consumptions
• Used clotting factories lead to

What does schis. Do to clots

• Cryo
• For inflammation, help stop
• High fluid to Vasopressor

Fluid Imbalance

• Monitor
• Fluid

Restruct

• Increase bUN and creatnine, retention
• Electrolyte Imbancew
• Restrict, Fluid Restriction
• Kidney Transpplant
• Are

What

• 4-4